Basic Information
| Provider Information | |||||||||
| NPI: | 1568616464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOHERTY | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CHARLEVOIX DR SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103344893 | ||||||||
| FaxNumber: | 8003251326 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085876556 | ||||||||
| FaxNumber: | 5085881694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 11/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 18333 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT33051 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2757 | HI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT015950 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10513 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1178633 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.